Electronic Nursing Record - Importance for Nursing and Benefits of Implementing it in Health Information Systems

1. Introduction

The evolution of nursing from a vocation to a scientific field is closely linked to the emergence of new areas like nursing methodology, nursing classifications, and the nursing process. These advancements necessitate the development of precise and specialized terminology that can ideally be standardized for comprehension by a wide range of nurses. Furthermore, the evolution of the nursing process and terminology naturally results in the need to document gathered evidence to achieve common objectives such as archiving, statistical analysis, research, and enhancement. Nursing documentation has traversed a long and challenging path, evolving from non-existence to paper-based records and now to the digital age with standardized care plans created automatically by purpose-built software. Different coutries are at different stages of this progression, and some have yet to fully embrace information and communication technologies. The objective of digitalization is not only to streamline numerous documentation processes but also to enhance and advance the fundamental essence of nursing, namely tailored patient care.

In the 1970s, the WHO recognized new technologies as essential tools for transferring and analyzing information to support the management of healthcare systems [1]. Since then, numerous countries have focused on organizing clinical information to enable patient-centered care and statistical analysis. However, medical documentation often lacks clear separation between nursing interventions and the contributions of other healthcare professionals. The introduction of electronic health records, which provide medical, administrative, and other data, has elicit the need to define the content of nursing records within these systems.

There are several examples in Western Europe that take nursing algorithms to a higher level, offering standardization, management, scaling, statistics, prediction, and quality management. The rapid development of information technologies has facilitated this progress, integrating digitization into all aspects of life. Digitization enables the creation of care plans, their standardization, and their consolidation into a nursing file. For instance, the information program Gacela-HIS (formerly Gacela Care) has been pivotal in Spanish healthcare since 1996 [2]. Developed and implemented step by step in collaboration with universities, nurse practitioners, hospital care facilities, and the Ministry of Health and its territorial divisions in the various autonomous regions of the Kingdom of Spain, Gacela-HIS streamlines various functions such as patient and bed availability, work plan scheduling, real-time patient condition monitoring, and the creation of individual nursing care plans [3]. Other software employed in Spanish healthcare, including Selene, OMI-AP, and AP-Madrid, incorporate modules for describing and recording nursing activities. Selene, from Siemens, embodies a comprehensive management approach to healthcare services, encompassing all patient interactions within the healthcare system [4]. The university environment also plays a crucial role in the integration of such software into clinical practice, as demonstrated by the implementation of WiseNurse, aimed at facilitating students' transition to work and the application of nursing diagnoses [5]. The ongoing trend focuses on enhancing information programs related to nursing diagnosis to select appropriate interventions and improve the quality of care. The introduction of electronic nursing files holds the potential to streamline work processes, track activities for evaluation, standardize nursing care, eliminate paper-based practices, provide data for attestation and quality assessment, offer resources for research, distribute tasks among nurses, and enhance overall activities. These software tools aim to consolidate input data to generate diagnostic hypotheses, defining characteristics, and connecting factors [6]. Furthermore, the pursuit of evidence-based practice in medical and nursing domains emphasizes the significance of standardizing care, making such patterns more attainable.

Nurses and midwives constitute the largest portion of the global healthcare workforce and should utilize standardized terminology in electronic health records (EHRs) [7]. To establish uniform and formalize nursing terminology and taxonomy, many countries utilize nursing classification systems. Unlike the International Classification of Diseases (ICD), they are not universal and each country chooses its own classification. However, most developed countries have adopted a nursing process model that involves nursing diagnoses, which are regularly reviewed every two years with the input of thousands of nurse practitioners from 32 countries [8]. Nursing diagnoses convey professional judgments made by nurses on a daily basis, defining nursing knowledge. Their application enhances nursing practice and establishes consistent standards for nursing care quality, which can then be validated. NANDA-I, in conjunction with the NOC (Nursing Outcomes Classifications) and NIC (Nursing Interventions Classifications), aims to develop and implement standardized terminology to ensure evidence-based care, enable reimbursement in hospital and outpatient settings, and enhance the quality of nursing care. Although based on functional models, nursing diagnoses in Europe form the foundation of nursing care plans, which are built on the conceptual model of Virginia Henderson, adopted by the International Council of Nurses (ICN) in 1955 (The Nature of Nursing) [9]. It is widely considered the most universal conceptual nursing model, despite a lack of data in the literature regarding its implementation process in any specific country, focusing instead on nurses' attitudes toward different models [10]. A specialized area of nursing science called nursing methodology examines and develops the nursing process using nursing taxonomy.

The present study aims to explore the significance of electronic nursing records, including nursing modules and software integrated with electronic health records, and to outline their primary benefits for nursing practice.

2. Materials and Methods

We conducted a scoping review using DECS-MeSH descriptors and Boolean operators; the Arksey and O'Malley protocol [11], the Joanne Briggs Institute (JBI) method [12], and the PRISMA flow chart of the Preferred Information Elements for Systematic Reviews and Meta-Analyses [13].

2.1. Search Strategy

We used four databases as sources: Medline (PubMed), Scopus, Google Scholar, and Cochrane Library. Articles in both English and Spanish were included without specifying their type. The study was confined to the last 20 years (2004-2024). The review followed the criteria outlined by Arksey and O'Malley [11]:

Phase 1: Identification of the research question.

Phase 2: Identification of relevant studies.

Phase 3: Selection of studies taking into account the inclusion and exclusion criteria.

Phase 4: Registration and presentation of data.

We conducted a preliminary search in various databases, including PubMed, EBSCO, and WoS, to define and refine the search strategy. Table 1 illustrates the strategy implemented between August 16 and 17, 2024, using Boolean operators and DECS-MeSH descriptors.

2.2. Data Analysis

The initial, or "identification," phase involved selecting manuscripts based on specific filters such as years of publication and language of the studies. The results were obtained by assessing titles, abstracts, and keywords. The second phase entailed conducting a full-text review to exclude any articles that did not meet the specified criteria. The following information was extracted from each article: database, author/title/year, country and/or city, type of study, objective of the study, and the leading conclusion or focal points.

3. Results

The initial search yielded a total of 6970 articles from four databases. Due to the broad inclusion criteria, the collaborative effort of three authors (VG-K, DT, and AK-B) was necessary to screen the results. As a result, duplicates and those whose titles did not correspond to the subject matter were removed. From PubMed, 583 duplicates and 2023 mismatches were removed; from Scopus - 433 duplicates and 2307 mismatches; from Google Scholar - 1 repeat and 9 not responding; and from the Cochrane Library, 313 duplicates and 1115 not responding. The results of the search are presented through the PRISMA flow chart in Figure 1.

Following the search, all identified articles were imported into Zotero 7.0.2 (Digital Scholar, Virginia, USA). This scoping review included 36 original papers, scoping reviews, literature and systematic reviews, as well as randomized and quasi-experimental trials. Generally, qualitative studies predominate. Table 2 outlines the primary characteristics of the chosen articles.

4. Discussion

This scoping review focuses on key topics relevant to the successful development and integration of standardized nursing electronic documentation within health information systems to positively impact nursing practice and theory and emphasize the significance of nursing care.

4.1. Ability to Work with Standardized Nursing Information Regarding Nursing Classifications

Several studies have highlighted the critical need for an appropriate taxonomy that not only supports the nursing process but also communication between individual units. In addition, from a theoretical perspective, nursing classifications establish and differentiate nursing terminology and language from that of other medical professionals. As noted by Hannah et al. [16], when discussing the situation in Canada (replicable in other countries), the focus is primarily on the information needs of physicians Despite nurses being the largest group of care providers in the Canadian healthcare system, the care they provide has a significant impact on clinical patient outcomes and yet remains largely invisible in most EHRs [16]. There are several classification systems currently in practice that aim to cover the essence of the nursing process on a broad scale. These systems involve the collection, analysis, and validation of information; making a nursing diagnosis; planning appropriate care and focusing on expected outcomes; implementing interventions, and evaluating the process. These systems are well-suited to operate in an electronic environment and serve as the basic building blocks of Electronic Nursing Records (ENR). Standardizing these systems can optimize the processes related to ENR and enhance the quality of patient care. In their study Heidarizadeh et al. [17] aim to demonstrate the effectiveness of standardization through the use of the CCC (Clinical Care Classification) system, concluding that CCC is a suitable method for standardizing nursing reports and enhancing the quality of electronic nursing records from a structural perspective. In addition to CCC, other systems such as the International Classification of Nursing Practice (ICNP), the Omaha System, and NANDA are commonly used examples of standardized nursing terminology. International research shows that the implementation and use of nursing standards in EHRs can increase the ability to distinguish, extract and analyze nursing care to improve quality and safety, including improvements in nurses' knowledge of evidence-based clinical guidelines [25]. A study in Norwegian practice showed that standardized care plans led to a reduction in administrative burden, improved documentation quality and enabled the identification of patient care needs and more effective management of long-term conditions [25]. A series of conferences in Nashville, Tennessee (USA) over the past 25 years has aimed to model and develop a standard nursing terminology that can be successfully integrated into reference information models such as HL7. The process of building the Nursing Information Reference Model (NIRM) as a standard for entering electronic nursing information within HL7 is outlined in the study by Goossen et al. [38]. The purpose of the study by Brazilian researchers was to examine the relationship between data and information in the nursing process, which were computerized according to ICNP® version 1.0, and to establish relationships between detailed clinical assessments of each human system and nursing diagnoses, interventions, and outcomes [45]. Evolutionarily, the process of standardizing nursing care is lengthy and labor-intensive due to the wide array of nursing knowledge and practices across different regions of the world. The American Nursing Association (ANA) emphasizes the importance of standardized terminologies as a significant means of facilitating interoperability between different concepts, nomenclatures, and information systems [50]. There is a high priority on the use of interoperable electronic health records, supporting data exchange between information systems, and generating secondary data for research [47]. A later study on the same topic and with the same lead collaborator (Westra et al.) [48] tracked over ten years of work on the USA National Action Plan for shared and comparable nursing data to support practice and translational research to transform healthcare. In another study by Müller-Staub et al. [49] the aim was to investigate the effect of directed clinical reasoning as a teaching method to promote nurses' abilities to use standardized language.

4.2. Improving Health Management, Increasing the Quality of Care and Reducing the Risk of Errors

Besides the aforementioned advantages of ENR, its main direction and prerequisite for its introduction is the improvement of patient-centred care, where efficiency, effectiveness, safety and quality are emphasized. Several studies have aimed to demonstrate the proportional relationship between the use of electronic records and the improvement of health care. In a prospective study, Zhang et al. [15] describe the potential for developing EHR quality control systems, which have a direct impact on the quality of care documented in electronic records. In their retrospective study, Chang et al. [32] analyzed data from quality audit software. The study was implemented to assess the status of EHR in a hospital in Taiwan with the aim of reducing errors. A pilot study among nurses in Israel on the effectiveness of EHRs in relation to errors, workload and availability of medical information leads to conflicting results in several directions and sets the stage for future studies [26]. Jayousi et al. [28] shared the experience of Italian nurses about their work with information technology and documented increased quality of care, optimization of health management, and professional satisfaction. A literature review by other Italian authors examines how the introduction of nursing data into electronic documents reduces the dispersion of information, promotes its sharing with other health professionals and contributes to multidisciplinary care management, leading to a better formulation of multidisciplinary therapeutic and health-educational plans [30].

4.3. ENR as a Prerequisite for Scientific Research

The information, generated electronically, is available in a database, which is a prerequisite for statistical processing and a large set of useful information to be selected and summarized in different types of scientific studies in the field of nursing. In general, all kinds of methods are needed to stimulate and improve scientific research in the field of nursing practice, and EHR and ENR are suitable sources for this. A literature review by Luan et al. [29] demonstrates the growing interest in research on electronic nursing records, their use and related elements, and the data they accumulate. Dionisi et al. [30], in addition to the above-mentioned advantages for nursing practice and health care, prove the existence of ENR as a prerequisite for the development of scientific research activity.

4.4. Impact of Electronic Records on the Behavior, Attitudes and Knowledge of Medical Professionals/Students

Most research has been done in the area of ​​qualitative and quantitative measurements of perceptions and attitudes of nurses, other health professionals, and students towards the use of electronic medical records. The reason is the desire to achieve improvements in the training process, the implementation and the very use of information technologies related to health care. Thanks to these studies, new strategies are consolidated, including relevant policy decisions, training programs at the university or hospital level, redistribution of resources, and adaptation of new technologies. All these steps aim at overcoming the change barriers (if any) to the implementation of electronic records and the implementation of the plan for all electronic health care. Many countries are yet to introduce similar types of resources into their health care systems, as is the case of Ethiopia, and a natural consequence of the process is a study on the willingness of health workers to use EHR and the factors that influence it [14]. Studies with similar objectives yield different results depending on cultural differences, the level of health education and some personality characteristics. A study by Ahn et al. [18], deals with the timeliness of entering information into the EHR and summarized that it depends on various factors, for example, the professional experience of the nurse. Other countries with more history in electronic records are conducting studies on whether the elements of the EHR meet the needs of users. Such is the case with the study of Stevenson et al. [19], who in 2010 concluded that Swedish nurses were not sufficiently satisfied with the EHR because it did not reflect their functions. Such studies are a prerequisite for the improvement of the relevant electronic systems and the introduction of nursing modules, ENR and the like within the information health systems. Brazil also introduced ENR relatively early in specific departments and focused efforts on improving worker perceptions of the new documentation system. The results are divided into three categories: favourable and unfavourable aspects of the introduction, as well as expectations of the process itself [20]. On the other hand, there are studies on specific elements of the ENR, such as the nursing report. Meum et al. [21] found that a greater share of the studied sample was satisfied with delivering nursing information this way. Another pioneer country such as the USA has already been working on the usability of EHR and ENR in 2009, demonstrating variation depending on the user interface with a constant drive for improvement [22]. In general, usability and functionality depend mainly on time efficiency for data entry and intuitiveness of systems, which facilitates the work of increasingly busy nurses. Another essential factor in the utilisation of electronic documentation systems is the level of training of the users. This is also proven by a Norwegian study by Laukvik et al. [25] involving nurses and Irwin et al. [27] with students in Australia. It is important to note that there are contrasting reports, in which, for some of the participants, one feature of EHR is a disadvantage, and for others, it is an advantage, as demonstrated by a study by Naamneh et al. [26]. In some works, such as the case described in the article by Topaz et al. [33], negative results are mentioned already in the title. The study is of considerable value, given its scale (45 countries and over 450 respondents) and defines the EHR problems perceived by medical professionals at that stage (2016) [33]. Despite the prevailing negative attitude towards electronic documentation, this type of research is positively focused on processes of improvement, correction and modification. Several studies aimed to identify those factors that determine nurses' attitudes towards information systems. In the UK, Winn et al. [39] attempt to demonstrate a relationship between demographic and other factors and attitudes toward electronic documentation based on the Unified Theory of Acceptance and Use of Technology (UTAUT). Some of these factors are gender, age, experience, voluntariness and appropriate conditions of use, as shown in the study by Alrasheeday et al. [41] in Saudi Arabia. In summary, the younger age of users, previous experience with information technology, and higher educational level are key factors in fostering a positive attitude towards EHR. Regarding technological skills, a Finnish study focused only on this factor, resulting in different levels of technological competence among users, which in turn led to a study of attitudes towards health information systems [40]. Proportionality between high technological competence and positive evaluations of the systems is proven [40].

Identifying those specific elements of electronic health records that do or do not function is at the core of the quest for many researchers. Depending on the country and the electronic system that is used, different components are assessed. However, nursing functions are similar and the usability of electronic documentation depends on workload, knowledge and skills, habits, and preferences. Lloyd et al. [43] surveyed nurses and physicians in Australia to find out exactly which items were rated as functional and useful and which were not. A similar approach was taken at the University of Tabriz (Iran) to evaluate implemented nursing software [46]. Despite the obtained results, their subjectivity should be taken into account, bearing in mind that technological evaluations require technological knowledge and experience. This is the case described in a study by Khudhayer Al-Aubaidy et al. [42], demonstrating the low level of knowledge about EHR in Iraq regardless of demographic differences or educational level.

4.5. Automation and Optimization of Processes

The concept of electronic healthcare revolves around optimizing services for better quality. Even new technologies like ENR can be improved. For instance, additional software can audit and optimize record quality, reducing input time, minimizing errors, and increasing satisfaction [15]. Traditional nursing duties, like nursing reports, have also been restructured for optimization. Norwegian hospitals achieved a major breakthrough in this area 15 years ago, emphasizing integrating new technologies into established processes [21].

Hyun et al. [22] emphasize the connection between nursing practice and supporting systems, highlighting the need for studies aimed at automating all records. Such a study is that of Rouleau et al. [24] in which the authors present a system for ENR optimization within the so called “nursing effectiveness framework". The stages are bilaterally oriented and contain: material/human resources and their management; converting resources into services; services produce specific changes in patients' conditions [24].

Various studies on EHR/ENR optimization involve users to improve electronic documentation. For example, a 2022 Canadian study engaged nurses to identify interventions for EHR redesigns [44]. In a study by Drnovšek et al. [36], students compare two information systems in Slovenian healthcare, aiming to encourage users' participation in developing future solutions. The Iranian nursing-oriented software, developed based on a literature review, addresses historically proven errors. The team emphasizes the meaningful involvement of end users during the development and implementation process as a critical condition for success [37].

4.6. Conditions for Implementation of Electronic Nursing Documentation

Progress is a one-way phenomenon and requires movement in the right direction. In the case of electronic documentation, nursing care should be an integral and mandatory part of it, serving to identify the role and place of the nurse in the process of patient care. Creating optimal conditions for the implementation of ENR is not an easy task and requires the participation of numerous institutions and the contingent of nurses themselves. Although the process of introducing W. Henderson's conceptual model in many countries has not been described anywhere, except for sentiments towards it [10], the implantation of ENR as a process in the new millennium has been documented in detail, something of great benefit to health systems that they haven't accepted it yet. An example of this is a study by Kleib et al. [34], which reflects the users' preliminary evaluation of a specific nursing file with educational purpose in undergraduate programs. The pilot study aims to detect feasibility issues for the implementation of the program and includes the views of students and faculty regarding the software itself [34]. The progress of ESD implementation in a South Korean university hospital and the benefits for nursing practice have been described in detail [23]. The specific software has a terminology server and a nursing documentation system, which demonstrates the importance of a technological resource for successful integration [23]. The aforementioned study by Strudwick et al. [44] used a three-phase scheme to specify the events that influence the effectiveness of the electronic documentation implementation processes: 1) determination and validation of the key indicators for nursing documentation; 2) identification of EHR usage trends and areas for improvement; 3) creation of ideas and their implantation through the necessary technological support. Another case is Brazil, which after 2010 has been working on the development and implementation of a computerized system reflecting the nursing process based on the international nursing standard ICNP [45]. Although at the time they recognized the applicability of the software only for the work of intensive care units, they emphasized the possibility of creating conditions for expanding the field of application in other structures and for more nurses [45]. The development of the integration of nursing standards in US EHR is the subject of the work of Westra et al. [48], in which, in addition to standardization, the conditions that led to this implementation are visible, namely: knowledge, practice, policies/resources and research activity. Early last and early this century, Canadian healthcare identified the need to implement electronic nursing documentation, which received significant support from the Canadian nursing community and other key healthcare leaders in each participating province [16]. The interpretation of these circumstances visualizes another necessary condition for implantation, namely unity. Another condition is described in the work of Bjarnadottir et al. [35] tracking EHR integration in USA nursing homes. With the representative sample of over 900 of these medical and social institutions, the conclusion is reached about the need for targeted policy and support for change. Countries with less experience, such as Iran, take advantage of the errors and shortcomings reported in the literature to build and implement their own nursing module with improved parameters, emphasizing the importance of the participation of future users in these processes [37].

5. Conclusions

In the era of universal digitization of healthcare, it is crucial for nurses to master electronic documentation systems in order to provide effective patient care [51]. The findings of this scoping review help in understanding the benefits and advantages of electronic documentation in improving nursing practice. It is important to emphasize the necessity of electronic nursing records, along with the essential elements and conditions required for their proper structuring, introduction, use, and the need for regular updating and upgrading. Most studies highlight advantages such as: enhancing theoretical knowledge and working with standardized nursing care plans, improving care management and coordination, increasing patient safety, streamlining administrative processes, and enhancing intra- and interdisciplinary communication.

The systematization can serve as a framework for medical institutions, universities, and politicians to effectively organize, monitor, and enhance the integration of electronic nursing documentation for improved patient care and healthcare management. We recommend conducting future systematic reviews to gather more detailed information on the issues addressed in this study.